Negative Appendectomies: Evaluating Diagnostic Imaging Techniques at General versus Pediatric Emergency Departments.

BACKGROUND: Although appendicitis is the most common pediatric surgical emergency, the path to diagnosis remains equivocal, with utilization of imaging modalities largely institution dependent. OBJECTIVES: Our objective was to compare imaging practices and negative appendectomy rates between patients transferred from nonpediatric hospitals to our pediatric hospital and primary patients presenting directly to our institution. METHODS: We retrospectively reviewed all laparoscopic appendectomy cases performed at our pediatric hospital in 2017 for imaging and histopathologic results. Two-sample z-test was used to examine negative appendectomy rates between transfer and primary patients. The negative appendectomy rates of patients who received different imaging modalities were analyzed using the Fisher's exact test. RESULTS: Of 626 patients, 321 (51%) were transferred from nonpediatric hospitals. The negative appendectomy rate for transfer patients was 6.5% and 6.6% for primary patients (p = 0.99). Ultrasound (US) was the only imaging obtained in 31% of transfer and 82% of primary patients. The negative appendectomy rate of US performed at transfer hospitals compared with our pediatric institution was not significantly different (11% vs. 5%, p = 0.06). Computed tomography (CT) was the only imaging obtained in 34% of transfer and 5% of primary patients. Both US and CT were completed for 17% of transfer and 19% of primary patients. CONCLUSION: The negative appendectomy rates of transfer and primary patients were not significantly different despite more frequent CT use at nonpediatric facilities. It may be valuable to encourage US utilization at adult facilities given the potential to safely reduce CT use in the evaluation of suspected pediatric appendicitis.

Describing the Patient Population of a Pediatric Emergency Department Based on Visit Frequency.

OBJECTIVE: A small number of children in the United States use a disproportionate share of emergency healthcare services. Our study objective was to examine characteristics associated with frequent pediatric emergency department (PED) utilization. METHODS: A retrospective cohort-sequential study of patients seen in the PED of an urban children's hospital was conducted. Patients were categorized into 2 groups: infrequent users (<4 visits during index year 2017) and frequent users (≥4 visits in 2017). Frequent PED users were further divided into persistent frequent (≥4 visits in the year before and after 2017) and incidental frequent (≥4 visits in 2017). Patient- and visit-level characteristics were analyzed for associations with PED utilization. RESULTS: In 2017, there were 82,361 visits by 56,767 patients to our PED. Frequent users comprised 4% of the total patient volume but accounted for 13% of visits. Compared with infrequent users, frequent users were younger, more likely publicly insured, and English speaking. Frequent user visits were more likely to occur outside clinic hours, be triaged as emergent, and involve subspecialists. Compared with visits by incidental frequent users, visits by persistent frequent users were more likely to be emergent or urgent, and involve subspecialists, diagnostic imaging, laboratory testing, and medication administration. CONCLUSIONS: Although the percentage of frequent users to a PED in 2017 was low, they made up a disproportionate share of total visits. Differences between persistent and incidental frequent PED users suggest that these subgroups may benefit from tailored interventions to reduce frequent PED utilization.

Text messages by wireless mesh network vs voice by two-way radio in disaster simulations: A crossover randomized-controlled trial.

BACKGROUND: Communication failures secondary to damaged infrastructure have caused difficulties in coordinating disaster responses. Two-way radios commonly serve as backup communication for hospitals. However, text messaging has become widely adopted in daily life and new technologies such as wireless mesh network (WMN) devices allow for text messaging independent of cellular towers, Wi-Fi networks, and electrical grids. OBJECTIVE: To examine the accuracy of communication using text-based messaging transmitted over WMN devices (TEXT-WMN) compared to voice transmitted over two-way radios (VOICE-TWR) in disaster simulations. Secondary outcomes were patient triage accuracy, perceived workload, and device preference. METHODS: 2 × 2 Latin square crossover design: 2 simulations (each involving 15 min of simulated hospital-wide disaster communication) by 2 modalities (TEXT-WMN and VOICE-TWR). Physicians were randomized to one of two sequences: VOICE-TWR first and TEXT-WMN second; or TEXT-WMN first and VOICE-TWR second. Analyses were conducted using linear mixed effects modeling. RESULTS: On average, communication accuracy significantly improved with TEXT-WMN compared to VOICE-TWR. Communication accuracy also significantly improved, on average, during the second simulation compared to the first. There was no significant change in triage accuracy with either TEXT-WMN or VOICE-TWR; however, triage accuracy significantly improved, on average, during the second simulation compared to the first. On average, perceived workload was significantly lower with TEXT-WMN compared to VOICE-TWR, and was also significantly lower during the second simulation compared to the first. Most participants preferred TEXT-WMN to VOICE-TWR. CONCLUSION: TEXT-WMN technology may be more effective and less burdensome than VOICE-TWR in facilitating accurate communication during disasters.

Leaving Without Being Seen From a Pediatric Emergency Department: Identifying Caregivers' Perspectives Using Q-methodology.

OBJECTIVE: National rates of left (or leaving) without being seen (LWBS) in pediatric emergency departments (PED) are higher than general emergency departments. We investigated coexisting perspectives on LWBS. METHODS: Q-methodology was implemented through a mixed-methods design. Semistructured interviews elicited a concourse of caregivers' thoughts on waiting in the PED and their consideration of LWBS. Themes from the concourse were identified and framed as statements. Caregivers sorted these statements, which ranged from choosing to stay versus leave the PED before their child is seen by a physician. Sorted data were analyzed through centroid factor analysis. RESULTS: Seventy-seven caregivers contributed interview data, from which 31 themes were identified and framed as statements. Thirty-one different caregivers contributed Q-sort data, from which 2 factors were revealed, each representing a unique perspective on LWBS. Most caregivers (26 of 31) shared the following perspective: "I would leave the PED before my child is seen by a doctor if there are no reassessments for my child while we are in the queue, no updates on our queue position, or no explanations for wait time." The remaining caregivers (5 of 31) perceived feelings of uncertainty and helplessness, lack of updates, and competing obligations as primary influences on LWBS. CONCLUSIONS: Elements that factor into caregivers' decision to LWBS from a PED include lack of reassessments, lack of updates on queue position, and lack of information about the triage process. Quality improvement interventions for decreasing LWBS rates should account for diverse coexisting perspectives such as these.

Teaching Infant Cardiopulmonary Resuscitation to Caregivers in the Emergency Department.

OBJECTIVES: Infant cardiopulmonary resuscitation (CPR) has been taught to caregivers of infants in inpatient settings. There are no studies to date that look at teaching infant CPR in the emergency department (ED). Using a framework of cognitive load theory, we compared teaching infant CPR to caregivers in a pediatric ED versus an inpatient setting. METHODS: Knowledge tests, 1-minute infant CPR performances on a Resusci Baby QCPR (Laerdal) manikin, and self-reported questionnaires were completed before and after caregivers were self-taught infant CPR using Infant CPR Anytime kits. The proportions of chest compression depth and rate that met quality standards from the American Heart Association's Basic Life Support program were measured. RESULTS: Seventy-four caregivers participated. Mean knowledge scores (out of a total score of 15) increased in both settings (ED preintervention: Mean (M) = 4.53 [SD = 1.97]; ED postintervention: M = 10.47 [SD = 2.90], P < 0.001; inpatient preintervention: M = 4.83 (SD = 2.08); inpatient postintervention: M = 10.61 [SD = 2.79], P < 0.001). Improvement in the proportion of chest compression that met high quality standards for depth increased in the inpatient group only. Neither groups had improvements in compression rates. There were no statistically significant differences in the difficulty of learning CPR, frequency of interruptions/distractions, or difficulty staying concentrated in learning CPR between the 2 settings. CONCLUSIONS: Caregivers in the ED and inpatient settings after a self-instructional infant CPR kit did not demonstrate adequate infant CPR performance. However, both groups gained infant CPR knowledge. Differences in cognitive loads between the 2 settings were not significant.

Reducing Abdominal Radiographs to Diagnose Constipation in the Pediatric Emergency Department.

OBJECTIVE: To determine the frequency of abdominal radiographs obtained in healthy children aged 6 months to 18 years to diagnose constipation in a pediatric emergency department, and evaluate the impact of quality improvement (QI) interventions on their use. STUDY DESIGN: QI study over 2.5 years at a large urban quaternary care children's hospital emergency department. Interventions consisted of educational presentations and individualized abdominal radiograph data reporting. The primary outcome measure was the percentage of abdominal radiographs performed on healthy patients discharged home with a diagnosis of constipation before and after QI interventions. RESULTS: The baseline total percentage of abdominal radiographs performed in otherwise healthy children discharged home with a diagnosis of constipation was 36% (October 2016 to January 2018). According to questionnaire results, ruling out obstruction was the most common reason for ordering an abdominal radiograph. After the QI interventions, the total percentage of abdominal radiograph decreased to 18% (April 2018 to March 2019). This 18% decrease was significant (P < .001) and sustained over a 12-month follow-up period. Throughout the study period, the average length of stay was 1.07 hours longer for children who had an abdominal radiograph. Clinically important return visits to the emergency department were uncommon during the postintervention phase (125/1830 [6.8%]), and not associated with whether or not an abdominal radiograph was performed at the initial visit. CONCLUSION: After these QI interventions, we noted a significant and sustained decrease in the percentage of abdominal radiographs obtained for otherwise healthy patients discharged home with a diagnosis of constipation.

Surge activation by the emergency department for COVID-19.

In March 2020, the American College of Emergency Physicians (ACEP) published a national strategic plan for COVID-19, which provides general guidelines yet leaves logistical details for institutions to determine. Key capabilities from this plan provided a crucial foundation for a 16-day Emergency Department (ED) surge planning process at one pediatric institution. This paper describes critical milestones and lessons learned during this brief period, including derivation of criteria for ED surge activation, a full-scale surge drill, and the resultant ED surge protocol. The framework of real-time evaluation was used throughout the planning process and involved constant and iterative synthesis of real-time feedback from multidisciplinary stakeholders for responsive decision-making. Ultimately, the objective of this paper is to provide timely and readily actionable information to other institutions seeking guidance to apply the ACEP strategic plan for COVID-19.

Evaluating Changes in Diagnostic Accuracy of Ultrasound for Appendicitis: Does Practice Make Perfect?

BACKGROUND: Ultrasound (US) is the preferred method of initial evaluation for appendicitis in pediatrics. However, limited accuracy of US for appendicitis is an obstacle to implementation of US-first protocols at facilities less experienced with US. OBJECTIVES: The primary objective was to demonstrate changes in diagnostic accuracy of US for appendicitis over time, after implementation of an US-first protocol. Secondary objectives included evaluating trends in utilization and factors associated with accuracy of US. METHODS: We reviewed 5 years of pediatric emergency department encounters that included US evaluations for appendicitis. The primary outcome was conclusive US (fully visualized normal appendix or unequivocal appendicitis) vs. equivocal US (partially visualized or nonvisualized appendix). We also analyzed rates of conclusive US over time; accuracy, sensitivity, and specificity of US for appendicitis; and associations of US accuracy with patient gender, body mass index, and ultrasonographer's experience. RESULTS: A conclusive US report was found in 267 of 1058 encounters (25.2%); overall accuracy rate was 24.5%. Over 5 years, the diagnostic accuracy of US for appendicitis improved significantly from 13.9% to 31.5% (p = 0.001). Overall sensitivity was 80.7% and specificity was 77.6%. Male gender and dedicated US of the appendix were significantly associated with conclusive US (ps < 0.001). Higher body mass index was significantly associated with equivocal US (p < 0.001). Ultrasonographer experience was not significantly associated with conclusive US (p = 0.22). CONCLUSIONS: An US-first imaging protocol for appendicitis in children shows chronologic improvement in diagnostic accuracy. This may provide encouragement to facilities using computed tomography-based diagnostic protocols to implement US-first protocols to reduce childhood radiation exposure.

Attitudes and Opinions of Adolescent Females Regarding 2 Methods of Bladder Filling for Transabdominal Ultrasound: A Q-Sort Study.

OBJECTIVES: Adolescent female patients who are not sexually active and who present to a pediatric emergency department with abdominal pain require a full bladder prior to transabdominal ultrasound. Procedures to fill the bladder are largely institution or provider dependent. We examined adolescent females' attitudes and opinions toward 2 common methods of bladder filling, intravenous fluid administration and transurethral Foley catheter placement, by means of a Q-sort study. METHODS: Two convenience samples of adolescent female patients in the pediatric emergency department at an academic children's hospital participated in the study. In part 1, subjects underwent a semistructured interview to elicit their opinions regarding 2 methods of bladder filling: intravenous fluid or transurethral catheter. The summation of subject statements was then narrowed down to a final Q set of 25 statements. In part 2, a second sample of subjects independently arranged this Q set according to their own agreement or disagreement with each statement. Principal components analysis was conducted to examine factors or collections of statements representing a shared viewpoint and to describe commonalities. RESULTS: Part 1 was completed with 9 subjects, and part 2 with 26 subjects. Factors revealed from the Q-sort data included acceptance of tests deemed medically necessary, desire for parental involvement, and a wish to minimize discomfort. Most adolescents aligned with 1 of these 3 factors. CONCLUSIONS: Adolescent female patients varied in their attitudes and opinions regarding intravenous catheter hydration and Foley catheter placement for transabdominal ultrasound. Knowledge of adolescent viewpoints may help better inform practitioner-patient communication for this procedure.

The effect of multimedia replacing text in resident clinical decision-making assessment.

Multimedia in assessing clinical decision-making skills (CDMS) has been poorly studied, particularly in comparison to traditional text-based assessments. The literature suggests multimedia is more difficult for trainees. We hypothesize that pediatric residents score lower in diagnostic skill when clinical vignettes use multimedia rather than text for patient findings. A standardized method was developed to write text-based questions from 60 high-resolution, quality multimedia; a series of expert panels selected 40 questions with both a multimedia and text-based counterpart, and two online tests were developed. Each test featured 40 identical questions with reciprocal and alternating modality (multimedia vs. text). Pediatric residents and rising 4th year medical students (MS-IV) at a single residency were randomized to complete either test stratified by postgraduate training year (PGY). A mixed between-within subjects ANOVA analyzed differences in score due to modality and PGY. Secondary analyses ascertained modality effect in dermatology and respiratory questions using Mann-Whitney U tests, and correlations on test performance to In-service Training Exam (ITE) scores using Spearman rank. Eighty-eight residents and rising interns completed the study. Overall multimedia scores were lower than text-based scores (p = 0.047, η p2  = 0.04), with highest disparity in rising interns (MS-IV); however, PGY had a greater effect on scores (p = 0.001, η p2  = 0.16). Respiratory questions were not significantly lower with multimedia (n = 9, median 0.71 vs. 0.86, p = 0.09) nor dermatology questions (n = 13, p = 0.41). ITEs correlated significantly with text-based scores (ρ = 0.23-0.25, p = 0.04-0.06) but not with multimedia scores. In physician trainees with less clinical experience, multimedia-based case vignettes are associated with significantly lower scores. These results help shed light on the role of multimedia versus text-based information in CDMS, particularly in less experienced clinicians.

Mental Health Screening Among Adolescents and Young Adults in the Emergency Department.

OBJECTIVE: To determine if a new, non-validated mental health screener can detect the prevalence of alcohol/drug abuse, traumatic exposure, and behavioral symptoms in adolescents and young adults seeking care in a pediatric emergency department (ED) for medical complaints. METHODS: An 11-item mental health screener (Emergency Department Distress Response Screener [ED-DRS] investigator developed) was created. Patients 12 years or older seen for medical complaints were assessed by physicians using the ED-DRS. Data were analyzed using the Kuder-Richardson Formula 20, χ test, Mann-Whitney U test, and Spearman correlation. RESULTS: Among 992 ED patients, mean age was 15.11 ± 2.10 years (46.2% boys; 53.8% girls). Approximately 77.9% were Hispanic/Latino. Symptomatic patients (S) answered "yes" to at least 1 ED-DRS item; asymptomatic patients answered "no" to all items. The S patients comprised 47.5% of the sample; asymptomatic patients comprised 52.5%. Among S patients, alcohol/drug abuse frequency was 14%. The traumatic exposure frequencies included: 33.5% physically or emotionally traumatized, 29.3% bullied, 21.2% physically abused, 8.1% touched inappropriately and 7.0% exposed to domestic violence. Behavioral symptom frequencies included: 33.8% depressed mood, 30.4% anxiety, 23.8% high energy behavior, 6.6% hallucinations, and 6.2% suicidal/homicidal ideation. CONCLUSIONS: Although patients present to the ED with medical complaints, they may be at risk for concomitant mental health problems potentially discoverable using the ED-DRS.

Cerebral Oxygenation and Acceleration in Pediatric and Neonatal Interfacility Transport.

OBJECTIVE: The purpose of this study is to measure peak acceleration forces during interfacility transport; examine whether drops in cerebral oxygenation occurred; and test the associations between cerebral oxygenation, acceleration, and patient positioning. METHODS: A cerebral oximeter (INVOS-5100C; Somanetics, Minneapolis, MN) monitored regional saturation of oxygen (rSO2 [cerebral oxygenation]) in pediatric and neonatal patients (N = 24) transported between facilities by ground ambulance, helicopter, or fixed wing aircraft. An accelerometer (GP1; SENSR, Georgetown, TX) bolted to the isolette or gurney recorded z-axis (aligned with the spine) accelerations. RESULTS: The z-axis peak accelerations (absolute values of g) by transport type were as follows: ground ambulance takeoff mean = 0.16 and landing mean = 0.08, helicopter takeoff mean = 0.16 and landing mean = 0.05, fixed wing aircraft takeoff mean = 0.14 and landing mean = 0.20. During takeoff, 2 of 7 patients in the head-to-front of vehicle position experienced rSO2 drop. During landing, 4 of 13 patients in the head-to-back of vehicle position experienced rSO2 drop. There were no significant associations of rSO2 drop during takeoff and landing with patient positioning or with z-axis peak acceleration. CONCLUSION: Acceleration forces of pediatric and neonatal interfacility transport are small and comparable in magnitude. The relationship between rSO2 drop and patient positioning was not significant in this pilot study.

Longitudinal trajectories of illness perceptions among adolescents with type 1 diabetes.

OBJECTIVES: To examine development in illness perceptions of type 1 diabetes across adolescence and relationships with intelligence, diabetes responsibility, and diabetes outcomes. METHODS: Illness perceptions were measured via the Illness Perceptions Questionnaire at 3 times, every 6 months in 213 adolescents (M age = 13.00; SD = 1.54) with type 1 diabetes. Intelligence and adolescents' perceived responsibility for diabetes were examined, and adolescents' report of adherence and quality of life (QOL), and glycosylated hemoglobin (HbA1c) from medical records addressed diabetes-related outcomes. RESULTS: Linear growth models showed significant increases in perceptions of diabetes coherence, chronicity, consequences, personal and treatment control, and decreases in diabetes cyclicality and parental control across time. More favorable illness perceptions were generally associated with adolescent intelligence at baseline, more adolescent responsibility for management, better adherence and QOL, and lower HbA1c at each time point. CONCLUSIONS: Results suggest that adolescents develop complex illness perceptions, which are associated with better diabetes management.

Traditional nurse triage vs physician telepresence in a pediatric ED.

OBJECTIVES: The objective of the study is to compare traditional nurse triage (TNT) in a pediatric emergency department (PED) with physician telepresence (PTP). METHODS: This is a prospective 2 × 2 crossover study with random assignment using a sample of walk-in patients seeking care in a PED at a large, tertiary care children's hospital, from May 2012 to January 2013. Outcomes of triage times, documentation errors, triage scores, and survey responses were compared between TNT and PTP. Comparison between PTP to actual treating PED physicians regarding the accuracy of ordering blood and urine tests, throat cultures, and radiologic imaging was also studied. RESULTS: Paired samples t tests showed a statistically significant difference in triage time between TNT and PTP (P = .03) but no significant difference in documentation errors (P = .10). Triage scores of TNT were 71% accurate, compared with PTP, which were 95% accurate. Both parents and children had favorable scores regarding PTP, and most indicated that they would prefer PTP again at their next PED visit. Physician telepresence diagnostic ordering was comparable with the actual PED physician ordering, showing no statistical differences. CONCLUSIONS: Using PTP technology to remotely perform triage is a feasible alternative to traditional nurse triage, with no clinically significant differences in time, triage scores, errors, and patient and parent satisfaction.

Reducing anxiety in the pediatric emergency department: a comparative trial.

BACKGROUND: Anxiety among patients in a pediatric emergency department (PED) can be significant, but often goes unaddressed. OBJECTIVE: Our aim was to determine whether exposure to Child Life (CL) or hospital clowning (HC) can reduce anxiety in children presenting to a PED. METHODS: Patients were randomized to CL, HC, or control and assessed upon entry to examination room (T1), before physician arrival (T2), and during physician examination (T3), using the modified Yale Preoperative Anxiety Scale (m-YPAS). CL and HC interventions occurred for 5 to 10 min before physician entry. Effects were analyzed using mixed analysis of variance. RESULTS: m-YPAS scores ranged from 23 to 59, with a higher score indicating increased anxiety. Mixed analysis of variance on the study sample (n = 113) showed a significant interaction between groups (CL, HC, control) and time (p = 0.02). Additional analyses indicated effect of group only at T2 (CL: mean = 23.8; 95% confidence interval [CI] 23.2-24.5; HC: mean 25.2; 95% CI 24.2-26.2; control: mean = 26.1; 95% CI 24.2-27.9; p = .02). Subanalysis of patients with T1 m-YPAS score ≥ 28 (n = 56) showed a significant interaction between group and time (p = 0.01). Additional analysis showed effect of group only at T2 (CL: mean 24.4; 95% CI 23.3-25.6; HC: mean 27.0; 95% CI 25.2-28.7; control: mean 29.2; 95% CI 25.6-32.7; p = 0.003). CONCLUSIONS: CL services can reduce state anxiety for patients presenting to a PED with heightened anxiety at baseline. This reduction occurred immediately after CL intervention, but was not observed in patients exposed to HC or during physician examination.

A Mixed Methods Needs Assessment for a Debriefing Intervention Following Critical Cases.

OBJECTIVE: The emergency department (ED) is a demanding environment, and critical events have been identified as contributors to stress. Debriefing is a possible intervention for staff, but there is little information regarding formulation and implementation. A needs assessment was conducted to describe the emotions of pediatric ED (PED) staff following critical events and assess opinions regarding debriefing. METHOD: This mixed methods study used convergent design for triangulation. After critical cases, PED staff members were given the Peritraumatic Distress Inventory (PDI). Additionally, a questionnaire with 2 open-ended questions on debriefing was administered. Themes were extracted from the questionnaire using directed content analysis. RESULTS: A total of 719 responses were collected for 142 critical cases. Physical reactions were often endorsed in the PDI, and these reactions were mirrored in the qualitative data, which included physiological responses such as stress, adrenaline high, anxiety, fatigue, and overwhelm. Helplessness and grief were 2 of the emotional PDI items frequently endorsed, which were reflected in the qualitative strand by themes such as helplessness, sadness, disheartenment, and regret. There was considerable variability between critical cases such that not every critical case elicited a desire for a debrief. CONCLUSIONS: PED staff report measurable levels of stress after critical patient cases that warrant follow-up. Formal debriefing immediately after critical patient cases with specific caveats may be valuable for the reduction of stress. Any formal debriefing program will need to balance various goals with attention to the session length, setting, and timing.

Mental Health Revisits at US Pediatric Emergency Departments.

Importance: Pediatric emergency department (ED) visits for mental health crises are increasing. Patients who frequently use the ED are of particular concern, as pediatric mental health ED visits are commonly repeat visits. Better understanding of trends and factors associated with mental health ED revisits is needed for optimal resource allocation and targeting of prevention efforts. Objective: To describe trends in pediatric mental health ED visits and revisits and to determine factors associated with revisits. Design, Setting, and Participants: In this cohort study, data were obtained from 38 US children's hospital EDs in the Pediatric Health Information System between October 1, 2015, and February 29, 2020. The cohort included patients aged 3 to 17 years with a mental health ED visit. Exposures: Characteristics of patients, encounters, hospitals, and communities. Main Outcomes and Measures: The primary outcome was a mental health ED revisit within 6 months of the index visit. Trends were assessed using cosinor analysis and factors associated with time to revisit using mixed-effects Cox proportional hazards regression. Results: There were 308 264 mental health ED visits from 217 865 unique patients, and 13.2% of patients had a mental health revisit within 6 months. Mental health visits increased by 8.0% annually (95% CI, 4.5%-11.4%), whereas all other ED visits increased by 1.5% annually (95% CI, 0.1%-2.9%). Factors associated with mental health ED revisits included psychiatric comorbidities, chemical restraint use, public insurance, higher area measures of child opportunity, and presence of an inpatient psychiatric unit at the presenting hospital. Patients with psychotic disorders (hazard ratio [HR], 1.42; 95% CI, 1.29-1.57), disruptive or impulse control disorders (HR, 1.36; 95% CI, 1.30-1.42), and neurodevelopmental disorders (HR, 1.22; 95% CI, 1.14-1.30) were more likely to revisit. Patients with substance use disorders (HR, 0.60; 95% CI, 0.55-0.66) were less likely to revisit. Conclusions and Relevance: Markers of disease severity and health care access were associated with mental health revisits. Directing hospital and community interventions toward identified high-risk patients is needed to help mitigate recurrent mental health ED use and improve mental health care delivery.

9-1-1 Activations from Ambulatory Care Centers: A Sicker Pediatric Population.

BACKGROUND: Pediatric patients transferred by Emergency Medical Services (EMS) from urgent care (UC) and office-based physician practices to the emergency department (ED) following activation of the 9-1-1 EMS system are an under-studied population with scarce literature regarding outcomes for these children. The objectives of this study were to describe this population, explore EMS level-of-care transport decisions, and examine ED outcomes. METHODS: This was a retrospective review of patients zero to <15 years of age transported by EMS from UC and office-based physician practices to the ED of two pediatric receiving centers from January 2017 through December 2019. Variables included reason for transfer, level of transport, EMS interventions and medications, ED medications/labs/imaging ordered in the first hour, ED procedures, ED disposition, and demographics. Data were analyzed with descriptive statistics, X test, point biserial correlation, two-sample z test, Mann-Whitney U test, and 2-way ANOVA. RESULTS: A total of 450 EMS transports were included in this study: 382 Advanced Life Support (ALS) runs and 68 Basic Life Support (BLS) runs. The median patient age was 2.66 years, 60.9% were male, and 60.7% had private insurance. Overall, 48.9% of patients were transported from an office-based physician practice and 25.1% were transported from UC. Almost one-half (48.7%) of ALS patients received an EMS intervention or medication, as did 4.41% of BLS patients. Respiratory distress was the most common reason for transport (46.9%). Supplemental oxygen was the most common EMS intervention and albuterol was the most administered EMS medication. There was no significant association between level of transport and ED disposition (P = .23). The in-patient admission rate for transported patients was significantly higher than the general ED admission rate (P <.001). CONCLUSION: This study demonstrates that pediatric patients transferred via EMS after activation of the 9-1-1 system from UC and medical offices are more acutely ill than the general pediatric ED population and are likely sicker than the general pediatric EMS population. Paramedics appear to be making appropriate level-of-care transport decisions.

Social Emergency Medicine: Capitalizing on the Pediatric Emergency Department Visit to Screen and Connect Patients and Families to Community Resources.

OBJECTIVE: To describe the social needs of families screened by the Community Health Advocates Team (CHAT) Desk, situated within a pediatric emergency department (PED); and to evaluate the effectiveness of this help desk in connecting families to community resources. METHODS: Trained undergraduates, onsite in the PED 30 hours/week during daytime and evening hours, weekdays and weekends, screened a convenience sample of families of patients in the PED for social needs, and provided information on available community resources. Families were offered a follow-up phone call several weeks after their PED visit to assess program satisfaction and success, and identify remaining social needs. RESULTS: Between January 2019 and March 2020, CHAT Desk screened and assisted 682 families. CHAT routinely provided resources about free outdoor recreational activities for families, but after that, the most commonly provided informational resources pertained to: health care (n = 200), housing (n = 143), and food (n = 137). Of families who completed the follow-up phone call (n = 294), almost half (n = 134, 46%) reported being able to contact at least one of the resources; 100 reported that the resource was able to assist them, and 99 families planned to continue using the resource. When asked about satisfaction, 93% (n = 274) reported being very satisfied or somewhat satisfied with CHAT; 94% (n = 276) said they would recommend it to others. CONCLUSIONS: The PED of a busy tertiary care children's hospital is an opportune location to screen families for social needs, and provide them with information on requested community resources.